Measuring Quality of Care for Co-Occurring Conditions

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Measuring Quality of Care for Co-Occurring
Conditions

• Richard C. Hermann, MD, MS Tufts University
  School of Medicine
• David J. Dausey, PhD Rand Corporation
• Amy M. Kilbourne, PhD, MPH University of
  Pittsburgh
• Catherine Fullerton, MD, MPH Harvard Medical
  School
• RWJF Depression in Primary Care Program
• Center for Quality Assessment Improvement in
  Mental Health
• www.cqaimh.org

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Overview

• Co-occurring conditions deficits in care
• Mental disorders SUD in primary care
• Medical conditions in mental health specialty
  care
• Dual diagnoses in mental health SU specialty
  sectors
• Role of quality measurement in improving mental
  healthcare
• Status prospects for measures of co-occurring
  conditions
• Breakout session
• Measure development exercise
• Measure selection exercise

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Mental disorders SUD in Primary Care

• Prevalence
• 5 - 27 of primary care patients have depressive
  or anxiety disorders
• 4 -10 of primary care patients have SUDs
• Deficits
• Poor recognition
• Low rates of use of brief screening tools
• Low rates of appropriate treatment in primary
  care
• Limited referral for specialty care
• Barriers to successful referral
• Poor communication btw. PCP and MH/SU specialists

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Medical Conditions among MHS Patients

• Prevalence
• Elevated rates of diabetes, HIV, pulmonary, CV
  GI disease among individuals with severe mental
  illness
• 2 - 5x higher risk of mortality from natural
  causes
• Deficits
• Lack of thorough medical evaluation for patients
  receiving MHS care for a psychiatric disorder
• 35 (3 - 92) psychiatric patients had a
  significant, undetected medical condition
• 50 (12 - 93) had a significantly undertreated
  condition

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Dual Diagnosis in MH SUD Specialty Sectors

• Prevalence
• 50 of patients with SMI have an SUD over
  lifetime
• 25 of patients with SMI have an active SUD
• Deficits
• lt 40 with dual diagnosis received any treatment,
  
• Only 8 receive integrated treatment
• Among pts in MH or SU specialty care, comorbid
  condition is frequently undocumented untreated

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IOM Crossing the Quality Chasm (2005)
Adaptation to Mental Health/Addictive Disorders

• IOM Recommendation 5-2
• Need to implement policies and incentives to
  increase collaboration among primary care, mental
  health, substance-use treatment providers to
  achieve evidence-based screening and care

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IOM Crossing the Quality Chasm (2005)
Recommendations on Measurement-Based QI

• Recommendation 4-2 / 4-3
• Clinicians provider organizations should
  measure continuously improve the quality of
  care they provide.
• Stakeholders need to reach consensus on
  standardized quality measures for comparative use

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National Inventory of Mental Health Quality
Measures

• gt 300 measures proposed for quality assessment
  improvement in MH/SUD care
• available at http//www.cqaimh.org/quality.htm
• Less than 5 assess care for co-occurring
  conditions
• Other instruments available, but not widely used
  for these populations
• surveys of patient perspectives of care
• outcome assessment tools
• fidelity scales

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Role of Measurement in Quality Improvement

• Internal quality improvement
• CQI aims, measurement, diagnosis, intervention
• system redesign
• External quality improvement
• reporting and feedback
• benchmarking
• contractual goals
• financial incentives
• consumer purchaser choice

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Framework for Measuring Quality of Care
Structure Process Technical Outcome
Structure Interpersonal Outcome
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Structures of Care for Co-Occurring Conditions

• Clinicians
• Competencies in detecting/ treating COC
• Availability of specialists for referral
• Facilities Services
• Availability of services across levels of care
• Adoption of structures to support COC care
• Clinical Information Systems
• Availability of medical records between sectors
• Procedures to safeguard confidentiality / consent
• Financing
• Reimbursement for care of COC

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Processes of Care for Co-Occurring Conditions

• Detection
• Assessment
• Access to specialty care
• Treatment vs. Referral
• appropriateness of decision
• referrals completion rate
• treatment underuse, overuse, misuse fidelity
• Coordination
• adequacy of communication / collaboration
• Continuity of care
• Safety

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Outcomes of Care for Co-Occurring Conditions

• Change in
• Symptoms
• Behaviors
• Functioning
• Quality of life
• Adverse effects
• Mortality
• Patient Satisfaction

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Desirable Characteristics of Quality Measures
Meaningful quality problem clinically important evidence-based valid comprehensible Feasible precisely specified data available affordable reliable confidential case mix Actionable under users control results interpretable
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Mental disorders SUD in Primary Care Existing
Quality Measures

• HEDIS measures adopted for health plans
• pts started on antidepressant for depression
  who remain on medication at 12 weeks 6 months
• children receiving medication for ADHD w/
  follow-up visit w/in 30 days, 2 additional visits
  w/in 9 months
• Service utilization for SUD
• treated prevalence any utilization in 12-months
• initiation 2nd service w/in 14 days
• engagement 2 additional services w/in 30 days

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Mental disorders SUD in Primary Care Measures
Under Development

• Structures supporting evidence-based practice
• of primary care practices using registries,
  rating scales, case management for depression
• Processes recommended for primary care practice
• patients screened for SUD
• of pts. diagnosed with alcohol abuse or
  dependence receiving a brief intervention
• pts. w/ depression receiving case mgmt support
• Outcome Measures
• average change in PHQ score at defined interval

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Mental disorders SUD in Primary Care Need for
Measures of Boundary-Spanning Care

• Potential measure topics
• Completion rates for referrals
• Communication btw PCPs and MHS
• Outcomes of referred or collaborative care
• Obstacles to overcome
• Carve-outs result in segregation of data btw.
  sectors
• Tension btw. sharing clinical information
  confidentiality
• Unclear accountability for outcome
• Lack of defined standards for boundary spanning
  care

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Measures of Conformance to Standards Guidelines

• Research Consensus
• Evidence Development
• Practice guidelines / standards of care
• Conformance
• Structures Processes Outcomes
• Delivery of Care

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Breakout Group 1 Measure Development
Information exchange between PCP MHS

• Proposed Measure
• primary care patients referred to MHS for
  psychiatric care whose PCP received adequate
  feedback
• Need for standards what? by when? how?
• What data sources are available?
• Different forms of measure useful to different
  stakeholders?

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Quality Measurement for Medical Conditions in
MHS Care

• Detection
• patients with general medical history
• patients with documented smoking status
• patients screened for DM, fasting lipids
• Treatment
• of patients receiving appropriate preventive
  care
• pap smear, vaccines, colonoscopy
• of patients with DM with HgA1c testing
• of patients with COPD with spirometry testing

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Background Integrated Care for MH/SUD

• 50 of individuals with a mental disorder have
  at least one co-occurring substance use disorder
  (MH/SUD)
• When compared to individuals with a single MH
  disorder individuals with MH/SUD have higher
• Rates of treatment utilization
• Use of emergency and hospital services
• Rates of violent behavior
• Risk of HIV infection
• Research for two decades has demonstrated that
  individuals with MH/SUD that receive integrated
  or linked care have better outcomes than those
  who receive silo care

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Deficits in Quality of Care for MH/SUD

• Limited current service linkages between MH and
  SA providers
• Failure to identify MH/SUD patients in MH
  specialty settings
• Program fidelity challenges
• Lack of performance measures despite growing
  evidence base and standards

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Structural Measure Service Linkages

• of programs that have
• Integrated services (MH and SA services in the
  same treatment program)
• Co-location (MH and SA services in the same
  location)
• Formal relationships (referral agreements or
  contractual relationships among providers)
• Informal or ad hoc (absence of formal
  relationships)
• Research indicates that programs with integrated
  services have the best outcomes

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Process Measure Model Fidelity

• Average fidelity score across participating
  programs
• New Hampshire/Dartmouth Integrated Dual Disorder
  Treatment (IDDT) model
• 26 Item fidelity scale
• Each item represents an org. or tx component of
  model
• Scores from individual programs can be compared
  to the mean score or a recognized benchmark
• Research indicates that Critical program
  components must be replicated to achieve good
  outcomes

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Outcome Measure Abstinence

• of patients with any SA diagnosis discharged
  from a MH specialty setting who report abstinence
  from drugs or alcohol over 6 months.
• MH specialty settings can be compared against the
  mean across all MH specialty settings or a
  recognized benchmark.

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Breakout Session 2 Measure Selection Integrated
Care for Patients with MH/SUD

• Comparing and contrasting different measures for
  MH/SUD
• Focus on measures for state mental health
  agencies
• Rate and discuss 3 different measures on
  feasibility and meaningfulness
• Consider appropriate data sources for measures

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Breakout Session

• Group 1 Measure Development
• Information exchange between PCP MHS
• Group 2 Measure Selection
• Integrated treatment for patients with dual
  diagnoses
• Report back 940 am